A mental health nurse is caring for a newly admitted client with obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?
Instruct the client on relaxation techniques for use when anxiety level increases.
Discuss many alternative coping strategies with the client.
Identify precipitating factors for ritualistic behaviors.
Provide a highly structured activity schedule for the client.
The Correct Answer is C
Choice A rationale: Instructing the client on relaxation techniques for use when anxiety level increases is a beneficial intervention for a client with OCD. However, it is not the first action the nurse should take. The nurse needs to understand the client’s condition, including the triggers for their ritualistic behaviors, before they can effectively guide the client in managing their anxiety.
Choice B rationale: Discussing many alternative coping strategies with the client is an important part of OCD management. However, this should come after understanding the client’s condition and the triggers for their ritualistic behaviors. Without this understanding, the coping strategies suggested may not be effective or relevant.
Choice C rationale: Identifying precipitating factors for ritualistic behaviors is the first action the nurse should take. Understanding what triggers the client’s OCD behaviors is crucial in developing an effective care plan. This understanding allows the nurse to work with the client to develop strategies to manage their triggers and reduce the frequency and intensity of their OCD behaviors.
Choice D rationale: Providing a highly structured activity schedule for the client can be helpful in managing OCD. However, this should not be the first action. The nurse needs to first understand the client’s condition, including the triggers for their ritualistic behaviors. This understanding will allow the nurse to develop a schedule that takes into account the client’s triggers and incorporates effective coping strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Protecting the client from injury is the highest priority nursing action in this scenario. Here's a detailed rationale explaining the importance of this action:
1. Imminent Risk of Harm:
Acute anxiety can significantly impair judgment and impulse control, escalating the risk of self-harm or harm to others. It's crucial to prevent any actions that could result in physical injury, even if unintended.
2. Physiological Manifestations:
Anxiety can trigger physiological responses that heighten the potential for harm, such as: Increased heart rate and blood pressure
Hyperventilation Diaphoresis
Agitation and restlessness Dissociation
These physiological changes can contribute to accidents, falls, or other injuries.
3. Impaired Decision-Making:
Acute anxiety often clouds rational thinking and decision-making abilities.
Individuals may engage in behaviors they wouldn't consider in a calmer state, such as running away, lashing out, or attempting self-harm.
The nurse's role is to safeguard the client from potential consequences of these impulsive actions.
4. Establishing Safety as a Foundation for Care:
Ensuring physical safety creates a necessary foundation for subsequent interventions.
Once safety is established, the nurse can proceed with assessing coping skills, identifying anxiety triggers, and implementing therapeutic strategies.
5. Protecting Others:
In rare cases, acute anxiety can manifest in aggression towards others.
The nurse must protect not only the client but also other individuals who may be at risk.
6. Ethical and Legal Obligations:
Nurses have a professional duty to protect clients from harm, upholding ethical principles and legal standards of care.
7. Preventing Trauma:
Physical injuries sustained during a crisis can exacerbate anxiety and complicate recovery. Proactive safety measures aim to prevent further trauma and promote healing.
I'll provide detailed rationales for the other choices in separate messages to ensure clarity and comprehensiveness.
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale: Expression of guilt feelings is a positive outcome in the treatment of conduct disorder. Guilt is an emotional response to one’s actions that are perceived as wrong or inappropriate. It is a self-conscious emotion that often involves a
sense of tension and regret. In the context of conduct disorder, the expression of guilt feelings can be seen as a sign of developing empathy and understanding the consequences of one’s actions. This is a crucial step in the process of behavior change and rehabilitation. The client showing signs of remorse during one-on-one counseling is a positive sign indicating that the treatment is having an effect.
Choice B rationale: A statement regarding unit rules is another positive outcome in the treatment of conduct disorder. Understanding and acknowledging the rules of the unit indicates that the client is beginning to accept the boundaries and norms set by the authority. This is a significant step towards improving their behavior, as individuals with conduct disorder often have difficulties following rules and respecting authority. The verbal altercation with another client could be seen as a negative event, but it also could indicate that the client is engaging with others, which could be a step towards improvement, depending on the context of the altercation.
Choice C rationale: A renewed relationship with an uncle does not necessarily indicate a positive outcome from the treatment of conduct disorder. While family support can be beneficial in the treatment process, it does not directly indicate that the client’s conduct disorder is improving. More information would be needed to determine if this is a positive outcome related to the treatment.
Choice D rationale: A positive attitude toward school is a positive outcome in the treatment of conduct disorder. School is a structured environment where rules and expectations are clearly laid out, and a positive attitude towards school can indicate that the client is beginning to accept these structures. This can be a sign of improvement in their behavior and attitude.
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